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Pain/Sedation:
Assessment and
Management
R. Blaine Easley, MD
Associate Professor
Depts. Of Pediatrics and Anesthesiology
Disclosures
• None.
Overview
• Review the prevalence and nature of common
“non-cardiac” pain in children with heart
disease.
• Review relevant studies of Pain and Sedation
Assessment issues in PICU.
• Provide insights into how perioperative pain
management may impact outcome from
cardiac surgery.
Definitions of Pain
“Pain is whatever the person says it is and
exists whenever he says it does.”
Margo McCaffery
• As defined by the International Association for
the Study of Pain (IASP)"an unpleasant sensory and emotional
experience associated with actual or potential
damage, or described in terms of such damage"
Prevalence of “Non-Cardiac” Pain
Med Clin N Am 94 (2010) 327–347
• Acute and Chronic pain conditions more prevalent in medical populations.
• 95% of reported pain in children is “non-cardiac” pain
• “chest pain” accounts for 0.3%-0.6% of pediatric ER visits.
Fig. 2
A Comparison of Symptom Prevalence
in Far Advanced Cancer,
AIDS, Heart Disease, Chronic Obstructive Pulmonary Disease
and Renal Disease
Journal of Pain and Symptom Management
Volume 31, Issue 1, Pages 58-69 (January 2006)
DOI: 10.1016/j.jpainsymman.2005.06.007
Journal of Pain and Symptom Management 2006 31, 58-69DOI: (10.1016/j.jpainsymman.2005.06.007)
Validation of the Pediatric Cardiac
Quality of Life Inventory
Marino BS, et al. Pediatrics 2010; 126; 498
“Cultural” context of Pediatric Pain
Parents
Surgeons
Patient
Physicians
Nurses
0
2
4
6
8
10
#3
#1
#2
Nurse Decision Making Regarding the Use of Analgesics and Sedatives in the
Pediatric Cardiac ICU*.
Staveski, Sandra; RN, PhD; Lincoln, Patricia; RN, MS; Fineman, Lori; RN, MS;
Asaro, Lisa; Wypij, David; Curley, Martha; RN, PhD
Pediatric Critical Care Medicine. 15(8):691-697, October 2014.
•Prospective Survey of CVICU nurses
•3 institutions
•217 patients
•1330 surveys
•70% of increases in sedative and
pain administration were related to
hemodynamic issues.
2
Impact on the Stress Response
•
•
•
•
•
•
•
•
•
•
Hyperdynamic circulation
Increased O2 consumption
Loss of body weight
Impaired immune function
Cardiovascular strain
Positive fluid balance
Vascular permeability
Hypercoagulability
Hyperglycemia
Catabolic metabolism (nitrogen loss)
Stress Response in Infants Undergoing
Cardiac Surgery
Anand et al. Anesthesiology 1990; 73: 661-670.
Stress Response partially eliminated by IV opioids
Anand et al. NEJM 1992; 326: 1-9.
Findings:
1) Neonates have a stress
response to pain that is partially
mitigated by opioids.
2) Mortality was reduced from
20-30% in the non-opioid group
to <10% in opioid treatment
group.
LARGE IMPACT:
Changed culture of neonatal pain
management.
How much is too much?
Anand et al. NEJM 1992; 326: 1-9.
High Dose IV Opioids
Positive:
• Stress reduction
• Pain elimination
• Cardiovascular
stability
• Reduce chronic pain?
Negative:
• Ventilatory depression
• Impair immunity
• Increased PICU stay
• Tolerance/withdrawal
Current Anesthetic Practice Variation for Norwood Stage 1
(average of 10 recent patients)
These graphs represent only
OR utilization and not
additional administration of
opioids or benzodiazepines in
the CVICU.
Unpublished data courtesy -Gaynor
JW, Pediatric Heart Network
presentation 4/2012
Adjunct Perioperative
Pain/Sedation Management
•
•
•
•
•
Benzodiazepines (midazolam/lorazepam)
Alpha-agonist (Dexmedetomidine/clonidine)
Acetaminophen
NSAIDS (Ketorlac and IV ibuprofen?)
Mixed mu receptor agonist/antagonist
(tramadol/butorphanol/buprenorphine)
• Ketamine
• Propofol
Dexmedetomidine: Pediatric Cardiac Surgery
Mukhtar AM et al, Anesth Analg 2006;103:52
•
•
•
30 pediatric patients, CPB and surgery for CHD
placebo vs. dexmedetomidine
– 0.5 µg/kg over 10 minutes → 0.5 µg/kg/hr
Dexmedetomidine group
– blunting of HR/BP response to skin incision and sternotomy
– blunting of catecholamine, cortisol, blood glucose change
Perioperative Pain and Sedation in CHDWhat’s new at TCH?
• Protocol-based Pain and Sedation Management
– Step based increases in opioid and benzo infusions.
• Sedation Stewardship Program
– Working with pharmacy and nursing to transition off
sedatives and analgesics
• Collaborative Learning Project
– Early extubation in TOF and Neonatal Coarc
• Standardizing intraoperative anesthetic
• Increased utilization of NCA/PCA
Pediatric Anesthesia 24 (2014) 266–274
0.77
MAC Hours
20
15
•Comparison between OR and ICU
Fentanyl and Benzodiazepine
exposures for the uninjured group
were not different (p=0.1641 and
p=0.3945, respectively).
10
5
0
Injured
Uninjured
Fentanyl
Equivalents (mcg/kg)
Total Inhaled Anesthetic
0.82
2500
2000
Injured
Uninjured
0.50
1500
1000
500
0
OR
ICU
0.89
Benzodiazepine
Equivalents (mg/kg)
150
100
0.68
50
0
OR
ICU
Injured
Uninjured
•There was a difference between OR
and ICU Fentanyl Equivalent exposure
for the injured group with greater
amounts received within the ICU
(p=0.0125).
•There was a difference between OR
and ICU Benzodiazepine Equivalent
exposure for the injured group with
greater amounts received within the
ICU (p=0.0309).
Pediatric Anesthesia 24 (2014) 266–274
Pediatric Anesthesia 24 (2014) 266–274
Potential Impact on Neurodevelopment
12 month – Bayley Scales of Infant Development III
Language
Motor
Injured p=0.1757
Uninjured p=0.6660
Injured p=0.0107*
Uninjured p=0.7109
Score
Cognitive
Injured p=0.0006*
Uninjured p=0.9878
Conclusion: 1) ICU LOS and new post-OP MRI most predictive of decreased 12-month
developmental scores across all domains.
2) VAA exposure had a negative impact on Cognitive scores. Opioids and Benzo had a mildly
positive impact
Summary
• Review the prevalence and nature of common
“non-cardiac” pain in children with heart
disease.
• Review relevant studies of Pain and Sedation
Assessment issues in PICU.
• Provide insights into how perioperative pain
management may impact outcome from
cardiac surgery.
Questions?
[email protected]
Management of Mild Pain
• developmental support
• parental involvement
• oral route of administration
•
•
•
•
Acetaminophen-excellent choice for mild post operative pain (hernias, etc)
especially in opioid-naïve patients
Ibuprofen - analgesic, non-narcotic NSAID; no studies to assess safety in
babies less than 3 months old
EMLA cream to prevent pain with planned procedures (circumcisions, etc.)
recommended in babies >36 weeks GA or > 2 weeks old
Sucrose is the most studied treatment to help babies deal with mild or
procedural pain, shown to help with LP’s, circumcisions, venipunctures, and
ECHO’s
– sucrose and sucking each cause the release of endorphins-putting these 2
treatments together has been proven to decrease pain in newborns
Management of Moderate Pain
• developmental support
• parental involvement
• oral route first, supplement with IV
• acetaminophen with oxycodone, given on a scheduled
and/or as needed basis
– AVOID codeine – 30% unable to metabolize into active analgesic form.
• ketorolac (torodal) - analgesic, non-narcotic, NSAID; time
limited use, works best when given around the clock for 48
hours post op in addition to other analgesics
Management of Severe Pain
• developmental support
• parental involvement
• pharmacological management
Opioid PCA/NCA - pain is better controlled if medication is given
prior to the climax of pain
• medications given on a prn basis result in peaks and valleys of
pain relief
• continuous drip or regularly scheduled doses maintain a constant
level of analgesia
Possible IV anxiolytic?
Pediatric Pain Assessment Tools
Johnson et al. AACN Advanced Critical Care 2012, 4: 415-434
Pediatric Sedation Assessment Tools
Johnson et al. AACN Advanced Critical Care 2012, 4: 415-434